INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 10, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mirmont Alcohol Rehabilitation Center d/b/a Mirmont Outpatient Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's October 2025 through July 2026 fire drill logs, the facility failed to ensure maintain a complete written fire drill log, which is to include the documentation of the exit route used and the amount of time it took for evacuation.
At the time of the inspection, the January 2026 fire drill log was missing which exit route was used and the amount of time it took for evacuation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Mainline Health Public Safety schedules and completes monthly unannounced fire drills with the Facility Director.
Mainline Health Public Safety completes all documentation for the completed Fire drills. This documentation has been updated and revised to include the exit route and the amount of time it took for evacuation for each fire drill to ensure compliance with fire drill documentation.
The Facility Director will monitor and audit the Fire Drill logbook every month to ensure that the monthly fire drills have included the updated and revised documentation showing the exit route and the amount of time it took for evacuation for each fire drill to demonstrate compliance for fire drill documentation. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project in one of one applicable client records reviewed.
Client # 8 was admitted to the outpatient activity on May 1, 2026 and was administratively discharged on June 15, 2026. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative discharges are
completed by the Behavioral Health
Therapists in collaboration/active
communication with the Clinical Supervisor and the Site Manager.
The Site Manager and the Clinical Supervisor were educated
during the DDAP survey on 9/10/26,
and again, by the Quality Manager on
9/11/26 on the regulatory requirement
that in the event of an administrative
discharge, client must be notified in
writing of a decision to involuntarily
terminate treatment, that the notice
shall include the reason for the
termination, and that the client shall
have an opportunity to request
reconsideration of a decision
terminating treatment.
Effective on 9/11/26, the process is that if a Behavioral Health Therapist identifies patient behaviors that may warrant an administrative discharge, the therapist will notify the Clinical Supervisor, and the Site Manager, and they will review the case together. If
deemed appropriate to perform an
administrative discharge, the
Behavioral Health Therapist will write
the discharge summary note and the
Site Manager will complete the
regulatory process by ensuring that the
patient was notified in writing of the
decision to involuntarily terminate
treatment, the reason for the
termination, and that the client had the
opportunity to request an appeal. In the
EMR, the Clinical Supervisor will
document these regulatory
requirements were performed during
the administrative discharge process.
All Behavioral Health Therapists were
educated by the Clinical Supervisor during their weekly Clinical Supervision on 9/14/26 regarding this process.
The Clinical Supervisor or designee will
perform audits monthly of all
administratively discharged clients to
ensure compliance with this regulation
and reinforce with staff as appropriate. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.
Client # 8 was admitted to the outpatient activity on May 1, 2026 and was administratively discharged on June 15, 2026. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative discharges are completed by the Behavioral Health Therapists in collaboration with the Clinical Supervisor and the Site Manager.
The Clinical Supervisor was educated during the DDAP Survey on 9/10/2026, and again by the Quality Manager on 9/11/2026 on the regulatory requirement that in the event of an administrative discharge, client must be notified in writing of a decision to involuntarily terminate treatment, that the notice shall include the reason for the termination, and that the client shall have an opportunity to request reconsideration of the decision terminating treatment.
Effective on 9/22/2026, the process is that if a Behavioral Health Therapist identifies patient behaviors that may warrant an administrative discharge, the therapist will notify the Clinical Supervisor, and they will review the case together. If deemed appropriate to perform an administrative discharge, the Behavioral Health Therapist will write the discharge summary note and the Clinical Supervisor will complete the regulatory process by ensuring that the patient was notified in writing of the decision to involuntarily terminate treatment, the reason for the termination, and that the client had the opportunity to request and appeal.
In the EMR, the Clinical Supervisor will document these regulatory requirements were performed during the administrative discharge process.
All Behavavorial Health therapists were educated on this process during their weekly supervision on 9/14/2026 regarding this process.
The Clinical Supervisor or designee will perform audits monthly of all administratively discharged clients to ensure compliance with this regulation and reinforce with staff as appropriate. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of five applicable client records reviewed.
Client # 9 was admitted to the outpatient activity on March 2, 2026 and was still active at the time of the inspection. A treatment plan update was completed on June 30, 2026 and the next update was due no later than August 30, 2026; however, the update was not completed at the time of the inspection.
Client # 10 was admitted to the outpatient activity on February 19, 2026 and was still active at the time of the inspection. A treatment plan update was completed on May 29, 2026 and the next update was due no later than July 29, 2026; however, the update was not completed until September 8, 2026.
Client # 13 was admitted to the outpatient activity on March 4, 2026 and was discharged on July 29, 2026. A treatment plan update was completed on April 1, 2026 and the next update was due no later than June 1, 2026; however, the update was not completed until June 16, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Behavioral Health Therapists are responsible for comprehensive treatment plan completion. The Clinical Supervisor gave education on 9/14/2026 to her Clinical team that all treatment plans need to be updated every 60 days to maintain compliance with the time frames outlined in the DDAP regulations.
The Clinical Team will use the resource in the EMR system to run a report that tracks compliance with comprehensive treatment plan completion as well as treatment plan updates. This report is projected to be built and validated for operational use by December 2026. Once the report is available, the new process will include the Clinical Supervisor will run the report biweekly (twice per week) and notify clinicians of upcoming deadlines for comprehensive treatment plans.
Client # 9 treatment plan will be updated by October 21, 2026.
The Clinical Supervisor will audit 10 charts per month to ensure treatment plan updates are completed every 60 days to demonstrate compliance for the treatment plan standard.
The Site Manager will audit 10 charts per month to ensure the Clinical Team is meeting the standards in Treatment Plans.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in three of five applicable client records reviewed.
Client # 8 was admitted to the outpatient activity on May 1, 2026 and was discharged on June 15, 2026. There was no follow-up information documented in the record at the time of the inspection.
Client # 11 was admitted to the outpatient activity on December 5, 2025 and was discharged on April 9, 2026. There was no follow-up information documented in the record at the time of the inspection.
Client # 12 was admitted to the outpatient activity on December 5, 2025 and was discharged on April 14, 2026. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility acknowledges the finding related to failure to consistently complete, and document 30-day post-discharge follow-up calls in accordance with facility policy and DDAP requirements.
To address this deficiency, the Clinical Supervisor was educated on the follow-up call process, associated policy requirements, and documentation expectations on September 10, 2026.
Effective immediately, Behavioral Health Therapists will notify the Clinical Supervisor whenever a patient is discharged from the program. The Clinical Supervisor will maintain a discharge tracking list of all patients requiring a 30-day follow-up call and will review the list weekly to ensure all required calls are completed within the designated timeframe.
The Clinical Supervisor will conduct and document all follow-up call attempts and outcomes in the electronic medical record (EMR), including successful contacts, unsuccessful attempts, voicemail messages, or any other applicable disposition.
To ensure ongoing compliance, a minimum of three discharged patient charts will be audited monthly by the Site Manager to verify that 30-day follow-up calls were completed and appropriately documented in the EMR.
Client # 8 was discharged on June 15, 2026, and a follow-up call will be completed on 10/12/2026.
Client # 11 was discharged on April 9, 2026, and a follow-up call will be completed on 10/12/2026.
Client # 12 was discharged on April 14, 2026, and a follow-up call will be completed on 10/12/2026.
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